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8�1ti '°N Wd9Z ti 8lOZ '8l 'rias alms PaAIaaa� <br /> ' WELLlPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DErARTMEPIT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)46BJ420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JoaADDRESS Comstock 'Rd ctrymiinden CA 95236 N <br /> m <br /> cRoss STREET()u n c a n R d APN 0 PARCEL SIZE LANo U, APPLtCAT ON if D <br /> 0 <br /> ( jky <br /> OWNER NAME T.a t-r r e n r P S a m b a d�Qt11r►1oa i{�f� C0�Q6 0 9—9 31—TTFF— <br /> _01 <br /> •1 HONE , <br /> OWNER ADDRESS T .Q .'- Box 461 / f o <br /> !Sox �/ CrMSTATEIz,PL i n d e n Ca 95236 <br /> CONTRACTOR Purviance Drillers , Inc PHONE 209-887-3554 <br /> CONTRACTOR AoDgEss PO Box 64 CITYISTA,EfZIP L in d e n , C A 95236 <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CRYfSTATE/Z1P <br /> LICENSE C-57 ❑C-61 0 D-09 o Other NUMBER 377923 DIPRATION DATE 7/3 1/19 <br /> DC*AESnC VVELLSAMPLC9G:C General Mineral/Coliform Bacteria(439 1)_Dibromochloropropane(4352)�Arsenic(4393) <br /> INTENDED USE 11PDomeSic/Private 7 InfgatlOWAgricuEWral ❑Industrial G Wafer Quality Morutonng ❑Soil SarnpCrtglCharacterization <br /> C Public Water System <br /> if d•f!ererd hom G1mer. Water System Name CoNEd Name or Pr t4Nnmper <br /> TYPE OF WORK O New Well C Repracement Well C Well AlteralionlModification D Other <br /> 0 Monitonng Well(S) It Of wells C Soil Baring(s) *09tbo'InW G Ceotechnical Aof borings <br /> O Out-Of-Service 1NeB 0 Out-OF-Service Well Renewal O Cross-CennerAon Repair <br /> D New Pump li Purrip Replacement C Pum Re air ❑Raise Well Casio <br /> WELL CONSTRUCTION <br /> Drilling Method n Mud Rotary G Ab Rosary O Auger ❑Cable Tool D Push Point n Olher <br /> Proposed Well Depth h Excavation in diameter G Open Bottom G Gravel Pa WGravel Size in diameter <br /> LI Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter,_in ThlcknessfGaugerASTM Schell C Slew C Plastic O Sfainkss Steri ]Other <br /> Grout seat Depth h D Neat Cement(94 f6 Da915-10 gal watetj U Sand Cement <br /> C Bentonite(20%solds) J Other sack r4z17 gal water <br /> Grout Placement Method 0 Pumped 0 Free Fall 3 Other 0 Retardant IAacelemtor(name) <br /> LEDInstalled By O Driller Pump ConYagar O Other <br /> n COncrute Pedestal C Dlmensionss VVidth f1 Length ftThick in l Christy Box 3 Stove Plpe <br /> PUMP i Submersible❑Turbine 0 Other HP Pump Set <br /> ft Blanding Water Level � f: <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WELL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS- I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WO COMPENSATION S. <br /> IN <br /> UM 4 VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9 3-76 7 <br /> SIGN '�� ` TlorPorate Secretard'ATE <br /> RE <br /> SEP I <br /> i <br /> ENVIRON <br /> PERM <br /> i <br /> i <br /> DEPARTMENT U E N <br /> Application Accepted try " ` Dale �"s Area <br /> Employee IDk��ul <br /> Grout rnspecgon By Dae� D SPECIAL Well Permit <br /> Pump Inspection By Oate :1 WAIVER Received V w9 YY��D <br /> Soil Boring Inspeclion By Date Constructed Well Depth �E <br /> COMMENTS <br /> 4018 <br /> PE SC Received Checkk{ Amount Perms AQu/ty v, <br /> C s Info B cash erTtltted Dale rm/oiee tl NM,;:t r'U 1Y <br /> Service Re t H W PiK;,'iAt <br /> 14 7 <br /> ENT <br /> EH303-06 ffMV16 <br /> WELL/PUVP 1`691117 <br /> E•d tiL9EL9260Z out saelluQ eoueiAind d99:E0 2L 9L deS <br />